Health inspection·September 29, 2023

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure assessments accurately reflected the resident's status for 1 of 6 residents (Resident #6) reviewed for accuracy of assessments. Residents Affected - Few The facility failed to ensure Resident #6's MDS accurately reflected the resident hearing loss. This failure could place residents at risk for not receiving care and services to meet their physical needs and promote feelings of well-being and quality of life. The findings include: Record review of Resident #6's, undated, admission Record, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #6 had diagnoses which included: unspecified hearing loss unspecified ear, speech, and language development delay due to hearing loss, cerebral infarction (stroke), and hemiplegia non dominant side (paralysis on one side of the body). Record review of Resident #6's Annual MDS, dated [DATE], Section B revealed the resident was able to hear adequately. Record review of the resident's care plan revealed the resident had a communication problem related to a hearing deficit. The problem start date was 4/7/20, and a revision date of 9/23/23. During an observation and interview on 09/26/23 at 12:03 PM revealed Resident #6 communicated by typing on his laptop computer that he could not hear, and he did not use hearing aids. He could not speak clearly, and he preferred to use the laptop to communicate his needs. In an interview on 09/28/2023 at 10:40 AM, the MDS Coordinator stated she did not have a facility policy for completing MDS assessments. She stated the admission MDS for Resident #6 was not accurately descriptive of his hearing status. She stated she completed the assessment and was responsible for all MDS assessments in the facility and she failed to document Resident #6's Section B accurately because she was in a hurry and made a mistake. She stated she followed the guidelines of the RAI Manual to complete assessments. She stated it was her expectation the MDS be documented to accurately reflect the resident's status. She also stated failure to not complete the MDS accurately could result in the resident not receiving needed care and services. She stated she would make a correction to the MDS. Interview with the DON on 9/28/23, at 11:00 AM revealed the MDS Coordinator was responsible for accurately completing the MDS. She stated failure to accurately document the resident's status in the (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 5 Event ID: 455574 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455574 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Weatherford 521 W 7th St Weatherford, TX 76086 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)